Provider Demographics
NPI:1467761130
Name:DANIELSON, NATHAN B (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:B
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 CONNECTICUT AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2554
Mailing Address - Country:US
Mailing Address - Phone:320-257-7787
Mailing Address - Fax:320-257-5596
Practice Address - Street 1:1990 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-257-7787
Practice Address - Fax:320-257-5596
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010177502085R0202X
MN1069492085N0700X
MN568492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1467761130Medicaid
MNH400143433Medicare PIN